Project Grant H79SM089103

OPEN SKY RAPID RESPONSE HUB. - THE BRIDGE OF CENTRAL MASSACHUSETTS, INC., DBA OPEN SKY COMMUNITY SERVICES (OPEN SKY) PROPOSES TO IMPROVE AND ADVANCE OUR CCBHC SERVICE DELIVERY CALLED THE OPEN SKY RAPID RESPONSE HUB (OSRRH) WHICH PROVIDES REAL TIME ACCESS TO INTEGRATED BEHAVIORAL HEALTH TREATMENT SERVICES AND REHABILITATIVE SUPPORTS. CURRENTLY THESE SERVICES ARE ACCESSIBLE 24/7 AND DELIVERED BY AN INTERDISCIPLINARY TEAM. SERVICE DELIVERY IS NOT BOUND TO THE FOUR WALLS OF THE CLINIC AND IS DELIVERED FLEXIBLY IN A VARIETY OF SETTINGS. WE UTILIZE PRACTICES THAT INCLUDE TRAUMA INFORMED CARE AND HOUSING FIRST PRINCIPLES AS VEHICLES FOR STABILIZATION AND ENGAGEMENT IN CCBHC SERVICES. OPEN SKY IS THE PRIMARY CCBHC AGENCY WORKING IN PARTNERSHIP WITH DESIGNATED COLLABORATIVE ORGANIZATIONS (DCO): FAMILY HEALTH CENTER OF WORCESTER, EDWARD M. KENNEDY COMMUNITY HEALTH CENTER, YOU, INC., RIVERSIDE COMMUNITY CARE, COMMUNITY HEALTHLINK INC., AND SPECTRUM HEALTH SYSTEMS, THAT WILL PROVIDE PRIMARY CARE, SPECIALIZED SERVICES FOR YOUTH AND FAMILIES, STATE-SANCTIONED CRISIS SERVICES AND SUBSTANCE USE TREATMENT, AS INDICATED, FOR THOSE ENGAGED IN OPEN SKY'S CCBHC. OPEN SKY RRH SERVES INDIVIDUALS THROUGHOUT WORCESTER COUNTY (POP. 862,11, US CENSUS), PROVIDING OFFICE BASED IN THE CITY OF WORCESTER OR THROUGH MOBILE OUTREACH. ACCORDING TO THE US CENSUS, 37% OF WORCESTER RESIDENTS SPEAK A LANGUAGE OTHER THAN ENGLISH IN THEIR HOME (2017-2021 AVERAGE), 23.9% ARE HISPANIC OR LATINO, AND 19.3% ARE IN POVERTY. OTHER PROVIDERS OFFER MENTAL HEALTH AND SUBSTANCE USE SERVICES BUT WITHOUT THE ARRAY OF HOUSING AND OTHER SERVICES DESIGNED TO ADDRESS HEALTH RELATED SOCIAL NEEDS OFFERED BY OPEN SKY. DURING EACH YEAR OF THE GRANT, THE OSRRH WILL SERVE 150 UNDUPLICATED INDIVIDUALS AND FAMILIES (600 THROUGHOUT THE LIFETIME OF THE PROJECT) WITH KNOWN AND CHRONIC CONDITIONS (SMI, SED, SUD, COD) AS WELL AS THOSE WHOSE WELLBEING HAS BEEN NEGATIVELY IMPACTED BY THE COVID-19 PANDEMIC. POPULATIONS OF FOCUS WILL INCLUDE THE HOMELESS, JUSTICE-INVOLVED, VETERANS, LGBTQIA+ YOUTH AND YOUNG ADULTS, AND SENIORS. WORCESTER COUNTY IS ONE OF THE MA COUNTIES HARDEST HIT BY THE OPIOID EPIDEMIC, ACCOUNTING FOR OVER 12% OF MA OVERDOSES IN 2021 (WWW.MASS.GOV). AMONG THE COUNTY'S JUSTICE-INVOLVED AND HOMELESS POPULATIONS THERE IS HIGH PREVALENCE OF MENTAL HEALTH CONDITIONS AND OVERDOSE, AS WELL AS LACK OF FOLLOW-UP CARE FOLLOWING AN OVERDOSE (UMASS MEDICAL, 2020). IN 2023, UNDOMICILED WORCESTER COUNTY RESIDENTS TOTALED 963, 45% OF WHOM ARE HISPANIC/LATINX AND 58% BIPOC (2023 PIT COUNT). OPEN SKY'S MISSION ALIGNS WITH THAT OF SAMHSA'S AND READS: BLENDING BEST PRACTICES WITH THE POWER OF COMMUNITY, WE PARTNER WITH INDIVIDUALS AND FAMILIES TO SEE BEYOND AND LIVE BEYOND PERCEIVED LIMITATIONS TO PURSUE FULFILLING LIVES. WE HAVE IDENTIFIED THREE OVERARCHING OUTCOMES FOR THE INDIVIDUALS AND FAMILIES WE SUPPORT THAT ARE TIED TO THE OPEN SKY APPROACH: WELLNESS, OPPORTUNITIES, AND RELATIONSHIPS. THE GOALS OF THE OSRRH ARE TO EMPOWER INDIVIDUALS AND FAMILIES TO ACHIEVE WELLNESS, BUILD RELATIONSHIPS, AND REALIZE OPPORTUNITY. WELLNESS OBJECTIVES INVOLVE EXPANDING OPEN ACCESS AND OUTREACH MODELS FOR DELIVERING EVIDENCE-BASED CLINICAL INTERVENTIONS THAT EQUIP PARTICIPANTS WITH THE SKILLS TO IMPROVE THEIR NEAR AND LONG-TERM BEHAVIORAL AND PHYSICAL HEALTH. BY ADDING CAPACITY FOR INTEGRATED PEER SERVICES, THE OSRRH WILL CONTINUE TO CREATE CONNECTIONS, NATURAL SUPPORTS, AND RECOVERY CAPITAL THAT WILL LEAD TO LASTING RELATIONSHIPS. TO ENABLE PARTICIPANTS TO REALIZE OPPORTUNITY, THE OSRRH WILL INTEGRATE HOUSING, EDUCATION, EMPLOYMENT, AND CASE MANAGEMENT SERVICES INTO PERSON-CENTERED CARE PLANS, OPENING PATHWAYS TO SELF-DETERMINATION AND SELF-SUFFICIENCY.